Enterococcus gallinarum meningitis: a case report and literature review

Catheter-Associated Vancomycin-Resistant Enterococcus faecium Ventriculitis and Multidrug-Resistant Acinetobacter baumannii Pneumonia With Subsequent Acinetobacter Ventriculitis: A Case Report

Ventriculitis is associated with cerebrospinal fluid (CSF) shunts, and rare microorganisms associated with infection include vancomycin-resistant Enterococcus (VRE) faecium and Acinetobacter baumannii. Both organisms are known to cause nosocomial infections, and the emergence of multidrug-resistant (MDR) strains presents a treatment challenge. There is a lack of consensus on antimicrobial agent selection for ventriculitis involving VRE faecium or MDR A. baumannii, which are life-threatening conditions. We present a case of a 59-year-old male presenting with CSF catheter-associated VRE faecium ventriculitis and MDR A. baumannii pneumonia who subsequently developed a nosocomial MDR A. baumannii ventriculitis. Both instances of ventriculitis were successfully treated with combination antibiotic therapy. VRE faecium ventriculitis was successfully treated with linezolid and intrathecal daptomycin. While daptomycin is not approved for Enterococcal infections, the synergistic effect of daptomycin in combination with linezolid proved effective. Although the MDR A. baumannii pneumonia was not cured with cefiderocol monotherapy, the MDR A. baumannii ventriculitis was successfully treated with combination therapy including cefiderocol, ampicillin/sulbactam, and intrathecal colistin. This highlights life-saving combination antibiotic therapies for ventriculitis caused by multiple rare and drug-resistant microorganisms.

Experience with enterococcal meningitis/ventriculitis in children

BACKGROUND

Enterococcal infections are increasingly common in hospitalized patients. Enterococcal meningitis/ventriculitis (EMV) is an extremely rare condition of enterococcal infections, occurring particularly in children. This study investigated the clinical and microbiological characteristics, predisposing factors, and prognosis in pediatric patients with EMV.

METHODS

Pediatric patients (<18 years) diagnosed with EMV were retrospectively evaluated over 10 years.

RESULTS

The study included a total of 25 isolates from 24 patients, median age 23 months (range: 1-136 months). The most common symptoms included vomiting, fever, and headache, with hydrocephalus shunt and preterm birth being the two most common conditions. Commonly associated infections, with central nervous system (CNS) devices as a predisposing factor, were due to external ventricular drainage and ventriculoperitoneal shunts. Two patients with spontaneous meningitis were preterm infant. Of the isolates, 44% were Enterococcus faecalis, 44% E. faecium, and 12% E. gallinarum. Five (20%) isolates were vancomycin resistant. Twelve patients were resistant to anti-enterococcal antibiotics, including ampicillin, ciprofloxacin, imipenem, teicoplanin, gentamicin, and linezolid (40%, 20%, 8%, 8%, 4%, and 4%, respectively). Enterococcus faecium was more resistant to ampicillin, ciprofloxacin, teicoplanin, and vancomycin than E. faecalis. The median treatment duration was 17 days (interquartile range: 14-26 days).The mortality rate was 8.3% (2/24; both associated with vancomycin resistance).

CONCLUSIONS

Neurosurgical conditions are the most common predisposing factors for EMV. Preterm birth is an important predisposing factor in children. Because EMV is nonspecific in clinical findings, it should be considered when there is an underlying CNS disorder and empirical treatment should begin in this direction.

Enterococcal meningitis/ventriculitis in Qatar-Experience with eight patients

Background & objectives: Enterococcal meningitis/ventriculitis (EMV) is a relatively rare condition that usually affects patients with underlying diseases. This study was designed to describe the clinical profile, laboratory parameters, treatment, and outcomes of EMV in patients admitted to Hamad General Hospital, Qatar.

Methods and material: This retrospective hospital-based study described the patients with EMV from 2009 to 2013.

Results: Eight patients were recruited for the study. Their median age was 42 years (21.50–53.75 years). Six patients (75%) were males, and two (25%) were females. Fever was the most common presenting symptom being present in seven (87.5%) cases. Six patients (75%) had nosocomial EMV, and all acquired the infection after placement of an external ventricular drain (EVD). The isolated species include seven (87.5%) E. faecalis and one (12.5%) E. gallinarum, and all of them were sensitive to ampicillin and vancomycin. In all patients with nosocomial EMV, the infected EVDs were removed, and the eight patients received empirical antibiotics that were modified upon receipt of culture results. All patients were cured, and no mortality was reported.

Conclusions: EMV is a recognized complication related to the introduction of EVD, whereas community-acquired enterococcal meningitis was reported among children who had no established risk factors or immunosuppression. Because of its nonspecific clinical presentation, treating physicians should have a high suspicion index.

Enterococcus gallinarum meningitis: a case report and literature review

Background

As an opportunistic pathogen, E. gallinarum mainly leads to nosocomial infections, and it’s multi-drug resistance has gained more and more attention. Central nervous system infections caused by E. gallinarum are rare, but have been reported more often in recent years. The previous cases were generally secondary to neurosurgery, especially ventriculoperitoneal shunts. In recent years, the cases largely occurred in patients with impaired immune function. The patient in our report may have had dual risk factors (immune impairment and an invasive surgical procedure).

Case presentation

The patient, a 35-year-old female, was admitted to our hospital for headaches of 3 days duration accompanied by nausea and vomiting for 2 days. The patient had fevers and chills for 3 days before admission; the peak body temperature was 38.5 °C. The patient had a splenectomy in our hospital 2 years earlier for thrombocytopenia and was thought to be immunocompromised. The abnormal findings on physical examination and laboratory testing were as follows: neck stiffness, present; lumbar puncture: pressure, 300 mmH₂O; Pandy’s test, positive; white blood cell (WBC) count, 1536 × 10⁶/L; monocyte count, 602 × 10⁶/L; monocyte percentage, 39.2%; multinucleate cell count, 934 × 10⁶/L; multinucleate cell percentage, 60.8%; protein, 1.08 g/L; WBC count, 21.1 × 10⁹/ L; neutrophil percentage, 85.3%; neutrophil count, 20.55 × 10⁹/L; C reactive protein (CRP): 136.4 mg/L; procalcitonin, 6.70 ng/mL. The patient was given meropenem (2.0 g, intravenous infusion, every 8 h) for anti-infection supplemented with other symptomatic support treatments. The patient’s fever and headache had no significant relief.

Conclusions

Central nervous system infections caused by E. gallinarum are rare, but should be suspected, particularly inpatients with impaired immune function or ineffective treatment. Avoiding long-term invasive treatment and improving immunity are helpful to reduce the occurrence of E. gallinarum infections. Early detection and diagnosis, as well as rational antibiotic use, are the keys to achieve satisfactory efficacy.

Clinical management of non-faecium non-faecalis vancomycin-resistant enterococci infection. Focus on Enterococcus gallinarum and Enterococcus casseliflavus/flavescens

Enterococcus gallinarum and Enterococcus casseliflavus/flavescens are enterococci intrinsically resistant to vancomycin belonging to the E. gallinarum group. They are responsible mainly for healthcare-associated infections, in particular bloodstream, urinary tract and surgical wound infections. Diseases due to these bacteria are significantly increasing worldwide, as they are prone to cause infection in patients with concurrent hepatobiliary or oncohematological disorders. Along with their distinguishing vancomycin resistance, due to a chromosomally-encoded VanC operon, their additional intrinsic resistance to many antibiotics other than glycopeptides limits the therapeutic choices. In addition, their intrinsic vancomycin resistance, unlike the vancomycin resistance of Enterococcus faecalis and Enterococcus faecium caused by transmissible plasmids, poses different infection control issues. We focused on the therapeutic and infection control issues of clinical syndromes caused by E. gallinarum and E. casseliflavus/flavescens. We propose therapeutic algorithms on bloodstream infections, endocarditis, central nervous system infections, endophthalmitis and urinary tract infections. The implementation of infection control measures in cases of E. gallinarum and E. casseliflavus/flavescens infection or colonization should be evaluated on a case-by-case basis, especially for epidemic outbreaks or for isolates supposed to harbor a potential transmissible vancomycin-resistance phenotype.

The first case report of Enterococcus gallinarum meningitis in neonate: A literature review

RATIONALE

Enterococcus gallinarum meningitis (EGM) is rarely found in normal adults and even rarer in children. To our knowledge, EGM in neonate has not been reported previously.

PATIENTS CONCERNS

Here we reported the first case of EGM in neonate. Prolonged fever was the only manifestation for the case after admission.

DIAGNOSES

Cerebrospinal fluid cultures showed that the isolate was Enterococcus gallinarum and sensitive to linezolid.

INTERVENTIONS

Ceftriaxone, beta lactam type, and vancomycin were used respectively, but not effective.

OUTCOMES

The temperature went down to normal after linezolid was used and the baby was discharged in good condition in the end.

LESSONS

This case indicated that EGM could also occur in neonate and fever could be the only obvious manifestation. Thus, the effective antibiotics and adequate duration are very important and linezolid is a potential good choice, especially for vancomycin-resistant patients.

Antibiotic-Induced Pathobiont Dissemination Accelerates Mortality in Severe Experimental Pancreatitis

Although antibiotic-induced dysbiosis has been demonstrated to exacerbate intestinal inflammation, it has been suggested that antibiotic prophylaxis may be beneficial in certain clinical conditions such as acute pancreatitis (AP). However, whether broad-spectrum antibiotics, such as meropenem, influence the dissemination of multidrug-resistant (MDR) bacteria during severe AP has not been addressed. In the currently study, a mouse model of obstructive severe AP was employed to investigate the effects of pretreatment with meropenem on bacteria spreading and disease outcome. As expected, animals subjected to biliopancreatic duct obstruction developed severe AP. Surprisingly, pretreatment with meropenem accelerated the mortality of AP mice (survival median of 2 days) when compared to saline-pretreated AP mice (survival median of 7 days). Early mortality was associated with the translocation of MDR strains, mainly Enterococcus gallinarum into the blood stream. Induction of AP in mice with guts that were enriched with E. gallinarum recapitulated the increased mortality rate observed in the meropenem-pretreated AP mice. Furthermore, naïve mice challenged with a mouse or a clinical strain of E. gallinarum succumbed to infection through a mechanism involving toll-like receptor-2. These results confirm that broad-spectrum antibiotics may lead to indirect detrimental effects during inflammatory disease and reveal an intestinal pathobiont that is associated with the meropenem pretreatment during obstructive AP in mice.

Proper use of antibiotics: situation of linezolid at the intensive care unit of the Tunisian Military Hospital

Linezolid was introduced in clinical practice in the early 2000s. It was considered to be an ideal reserve drug for treatment of vancomycin-resistant Enterococcus spp. (VRE) and vancomycin-resistant Staphylococcus aureus (VRSA). The aim of our study was to describe and evaluate the use of linezolid in clinical practice at the intensive care unit (ICU) of the Tunisian military hospital. This is a thirty-month retrospective study including patients treated with linezolid at the ICU of the Tunisian military hospital. Data collection was realized using the patients' medical files and prescriptions. A pharmacist conducted an extended medication history and checked if an advice from an infectious disease-physician and a microbiological documentation were requested. A total of 80 patients were included. Forty-one per cent of indications were outside the Marketing Authorization (MA) criteria, and were mainly sepsis and postoperative mediastinitis (32% and 4% of total prescriptions, respectively). This antibiotic was used as a first-line therapy in 58% of cases. The advice from an infectious-disease physician was requested for 33% of prescriptions. Only 20% of infections were documented microbiologically, of which 35% were caused by methicillin resistant coagulase-negative Staphylococcus. Linezolid is an interesting therapeutic alternative in case of infections due to multi-resistant bacteria and/or complex clinical situations. Therefore, its prescription must be rationalized in order to slow down the emergence of resistance to this antibiotic. The high frequency of its use outside the MA criteria shows the importance of carrying out more clinical trials to evaluate its effectiveness and safety for new indications.

An unusual etiology of post-traumatic meningitis

Clostridium perfringens and related species are well-known culprits of post-traumatic soft tissue and bone infection. However, central nervous system involvement with these organisms spontaneously or subsequent to trauma is unusual. The authors reported a case of post-traumatic meningitis in which both C perfringens and Enterococcus faecium were isolated.

Enzyme deactivation treatments did not decrease the beneficial role of oat food in intestinal microbiota and short-chain fatty acids: an in vivo study

BACKGROUND

Steaming and roasting treatments are widely used enzyme deactivation methods in the oat food industry in China. Whether or not the enzyme deactivation treatments affect the nutritional function of oat foods is unknown. In the current study, we examined the effects of 4-week ingestion of steamed or roasted oat foods on the intestinal bacteria and short-chain fatty acids of rats.

RESULTS

Compared with rats taking no oat foods, rats taking normal oat foods or enzyme-deactivated oat foods showed significantly higher (P < 0.05) counts of Lactobacillus spp. and Bifidobacterium spp. in colon, significantly lower (P < 0.05) counts of Enterococcus spp. and coliforms in colon, and significantly higher (P < 0.05) levels of butyrate and acetate in colonic digesta. In addition, rats taking infrared roasting (IR)-treated oat foods also demonstrated significantly higher (P < 0.05) fecal Lactobacillus spp. counts and significantly lower (P < 0.05) cecal and fecal counts of E. coli, Enterococcus spp. and coliforms than rats taking no oat foods. As for the comparison between the enzyme-undeactivated oat group and the three enzyme-deactivated oat groups, there were no significant differences in most of the parameters (P > 0.05), though a few exceptions did exist.

CONCLUSION

Enzyme deactivation treatments did not decrease the beneficial role of oat food in the intestinal microbes and short-chain fatty acids of rats.

Fatal meningitis caused by vancomycin-resistant enterococci: report of two cases from south India

Vancomycin-resistant enterococci rarely cause meningitis and present a therapeutic challenge. Antimicrobial susceptibility testing was done for strains of Enterococcus species isolated from CSF samples of patients with meningitis by phenotypic methods. Multiplex polymerase chain reaction was performed to determine the genetic basis of vancomycin resistance of such isolates. We report here two cases of enterococcal meningitis caused by vancomycin-resistant Enterococcus species. One of the isolates was identified as Enterococcus faecalis and the other as Enterococcus gallinarum. We also report the simultaneous presence of vanC1 and vanA resistance genes in the strain of E. gallinarum. To the best of our knowledge, this is the first report of vanA resistance gene in an isolate of E. gallinarum from the Indian subcontinent. This is also the first Indian report of vancomycin-resistant Enterococcus causing meningitis.